HROB Stickers--Problems/Plans

Last updated 11/19/2024

2 VESSEL UMBILICAL CORD

               See Guideline for Management of isolated soft ultrasound markers for aneuploidy in the second trimester

ADRENO-GENITAL SYNDROME, previous child and same FOB

               At 10 weeks, draw MaternaT 21 to determine fetal sex.

               When results of MaternaT 21 are complete, send Perinatology referral for a plan of management.

               DO NOT start high dose dexamethasone.

ADVANCE MATERNAL AGE, age 35-39

          Recommend MaternaT 21 at 10-12 weeks before the patient’s appointment in Anchorage at 20 weeks

Offer 2^nd trimester MSAFP screen

              Recommend referral to Perinatology for DAFUS and Genetic Counseling.

ADVANCE MATERNAL AGE, age 40 plus

               Recommend MaternaT 21 at 10-12 weeks before the patient’s appointment in Anchorage at 20 weeks

Offer 2^nd trimester MSAFP screen

              Recommend referral to Perinatology for DAFUS and Genetic Counseling.

              NST-AFI weekly starting at 36 weeks

              Recommend delivery by EDD

ALLERGY TO PENICILLIN

               If GBS positive, GBS culture will automatically reflex in lab for sensitivity to clindamycin and erythromycin.

AMNIOTIC BAND/

               Refer to Perinatology

ANEMIA, Hg <11

               Follow Anemia in pregnancy guideline

             

ASYMPTOMATIC BACTURIA

               Test of cure (TOC) at next appointment

               Urine culture every visit

               Treat any level of bacteriuria

cardiac anomalies in fetus, current pregnancy

               If suspected anomaly found during screening ultrasound in Bethel, contact HROB and Perinatologist for a plan of care.

               Document plan of care in patient note and problem list

               Return to HROB meeting after the ANMC visit to discuss and plan for subsequent care.

Chronic Hepatitis B Virus (HBV) Infection

               HbsAg positive

               Draw Liver Enzymes, HBV DNA

               If HBV DNA detected with a specific titer over 10IU, refer to Hepatology for possible anti-viral therapy.

               If HBV DNA not detected or detected <10IU, do not sent referral.

               ALL neonates born to mother with a positive HBsAg WILL receive HBIG and HBV vaccine at birth with parental consent.

CHRONIC HYPERTENSION

               Consult HROB or OB/GYN on call at 1^st prenatal visit or at diagnosis

               Baseline testing: Urine protein/creatinine ratio, comprehensive metabolic panel.

               Consider EKG/Echocardiogram if longstanding hypertension or multiple medications.  HROB meeting will decide if these are necessary.

Consider Stopping medication and rechecking blood pressure in 1 week.

Change Medication to labetalol or metoprolol if possible, if on amlodipine, ok to continue

              Aspirin 162mg daily from 12 weeks until delivery

              Ultrasound for growth weeks 24, 28, 32, 36

              Start antenatal testing at 34 weeks, BPP weekly

              Repeat labs for suspected superimposed Preeclampsia, if found, contact HROB or OB/GYN for plan of care.  Discuss at every prenatal visit with HROB or OB/GYN.

              Consult obstetrician at 37 weeks for delivery plan

CONGENITAL ADRENAL HYPERPLASIA, previous child

               At 10 weeks, draw MaternaT 21 to determine fetal sex.

               When results of MaternaT 21 are complete, send MFM referral for a plan of management.

               DO NOT start high dose dexamethasone.

DIABETES, PRE-PREGNANCY

              Aspirin 162mg daily from 12 weeks until delivery

Consult Obstetrician for medication

              Recommend insulin starting with NPH.

              Baseline testing: Protein/creatinine ratio, comprehensive metabolic panel, TSH.

              Consider EKG/Echocardiogram if longstanding disease, severe/brittle disease or co-morbid conditions.  HROB meeting will decide if these are necessary.

              Optometry referral

              Recommend 1^st Trimester screening for aneuploidy, using MaternaT 21

              Refer to Perinatology for DAFUS, Fetal Echo and consultation

              Transfer of Care to Anchorage depends on patient adherence to plan of care and glucose control.  Could be any time from 30 weeks to 35 weeks.

DILATED FETAL RENAL PELVIS (UTD)

               See Guideline for Management of isolated soft ultrasound markers for aneuploidy in the second trimester

ELEVATED MSAFP

               Verify information sent to LabCorp for calculating results

               Obtain ultrasound for dating if not already done.

               Resubmit for recalculation if necessary

               If AFP MOM <3.0, repeat AFP.  If MOM still >2.5, or initial result is >3.0, refer to Perinatology for DAFUS and genetic counseling.

               In third trimester, watch for: IUGR, preeclampsia, preterm labor, vaginal bleeding.  Consult HROB or OB/GYN if these occur.

               Ultrasound at 32 weeks or as directed by the Perinatologist

FETAL GROWTH RESTRICTION, Suspected

               Obtain an ultrasound for fetal Growth

               If US shows EFW<10%,

               Obtain cord Doppler

               Send images to Perinatologist

               Follow recommended plan of care from Perinatologist

               If ultrasound shows EFW>10%, contact HROB or OB/GYN for plan of management.

GENITAL HERPES

               Inspection of vulva and vagina at 36 weeks and in labor

               Encourage valacyclovir 500mg BID for prophylaxis at Be in Bethel visit or 4 weeks before planned delivery

Gestational Diabetes

               Goal: Fasting <95, 2 hour postprandial <120 or 1 hour postprandial <140

               Close monitoring until controlled (weekly visits or contact).

               Weekly discussion at HROB rounds

               Growth US at 36 weeks

               If poor control (>25% of values above goal)

                               consider medical therapy (insulin(preferred) or oral medication)

                              stay in Bethel after 32 weeks

               If the patient is not providing data through finger stick glucose monitoring, offer Continuous glucose monitor.

               If the patient is not providing any data from any method of testing, transfer to Anchorage at 35 weeks or sooner.

              

GESTATIONAL DIABETES, POOR CONTROL

               Consult HROB or OB/GYN at every visit for patients in poor control (>25% of values above goal) to update the plan of care.

               Transfer to Anchorage at 32 weeks

GESTATIONAL DIABETES, ON MEDICATION

               Insulin is preferred medication.  Only use oral medication if the patient refuses insulin.

               Goal: Fasting <95, 2 hour postprandial <120 or 1 hour postprandial <140

               Close monitoring (weekly visits or contact).

               Weekly discussion at HROB rounds

               Adjust medication weekly until goal achieved.

               Weekly BPP after 32 weeks. (stay in Bethel)

               Transfer to Anchorage at 32-35 weeks depending on patient participation with the plan of care and glucose control.

GESTATIONAL HYPERTENSION/PREECLAMPSIA in current pregnancy

               Prenatal visits twice a week

               Weekly Labs CBC, CMP, protein/Creatinine ratio. 24-hour urine as recommended by HROB or OB/GYN physician.

               NST 2x/week, AFI weekly

               US OB follow-up for growth every 3 weeks

                               If Growth restriction suspected, contact HROB or OB/GYN for a plan.

               Consult with HROB or OB/GYN at EVERY VISIT

               Refer to North Wing Physician for delivery at 38 weeks

Gestational pruritus

               Do not start Ursodiol

               Repeat Bile Acids and LFT every 1-2 weeks.

GESTATIONAL PRURITUS WITH LAB ABNORMALITIES OR SEVERE PRURITUS

               Lab abnormalities: Cholic acid > 3.0, elevated AST, ALT, bilirubin or alkaline phosphatase > 300.

               Severe itching is excoriations, scratching during appointment, itching that alters sleep

               Start ursodiol 600mg po BID.  Treat as Cholestasis.

               NST weekly after 32 weeks.

               Induce at 39 weeks.

                

GRAND MULTIPARA (5 or more deliveries)

               Active management of 3^rd Stage recommended

               Discuss Birth Control Plans at 36 weeks

               Sign Sterilization consent at 20 week visit, if considering sterilization

GROUP B STREP BACTERIURIA in current pregnancy

               Any level of GBS in the urine at any time of the pregnancy initiates this plan

               Do not do screen with vaginal/rectal swab at 36 weeks.

               Begin prophylaxis in labor per guideline.

GROUP B STEP, PREVIOUS BABY WITH INVASIVE DISEASE

               Screen for bacteriuria per the routine.

               Do Not screen with vaginal/rectal swab at 36 weeks.

               Begin prophylaxis in labor per guideline.

GROUP B STEP, PREVIOUS PREGNANCY WITH POSITIVE CULTURE AT TERM, BUT NO NEONATAL INFECTION

               No treatment is indicated

               Screen at 36 weeks per routine protocol

HBsAg POSITIVE, NEW FINDING

               Draw LFTs, HB core IgM, HBeAg, HBeAb, HBsAb, HB DNA PCR

               Refer to ANMC hepatology

HIGH RISK FOR PRETERM BIRTH

               Reason:

               HROB meeting discussion or consult OB/GYN

               If recommended, start progesterone 200mg per vagina qhs 16 – 36 weeks

               Urine culture every visit

               Serial cervical length every 2 weeks from 16- 24 weeks

                               If cervical length less than 30mm, see sticker for short cervix of the “Guideline Preterm Labor: Screening and Prevention”

               Treat BV if symptomatic (screening for BV is not indicated)

HISTORY OF DEPRESSION/POST PARTUM DEPRESSION

               Screen every visit for depression

               Contact ACT or Behavioral Health for score >9

               Consider SSRI postpartum

HISTORY OF DOMESTIC VIOLENCE

               Discuss at every visit.

               Monitor for signs or symptoms of abuse

               Offer counseling or referral for services.

HISTORY OF INTRAHEPATIC CHOLESTATIS

               Draw baseline total bile acids and liver enzymes at first visit

               Monitor for symptoms at every visit

               If severe clinical symptoms, redraw labs above and begin Ursodiol 600 mg BID.

               See guideline

HISTORY OF IUGR OR SMALL FOR GESTATIONAL AGE (SGA) <20% FETUS

               Growth scans at 24, 28, 32 and 36 weeks

HISTORY OF A LARGE FOR GESTATIONAL AGE (LGA) >90% FETUS OR >4000GM

               Screen for Gestational Diabetes per protocol

               Ultrasound at 36 weeks for growth

HISTORY OF MOLAR PREGNANCY

               Make sure first trimester US has history of Molar pregnancy as a diagnosis

               Review the US with HROB physician

               Refer patient to HROB meeting

               Send Placenta for pathology after delivery.

HISTORY OF POSTPARTUM HEMORRHAGE

               Second IV in labor

               Standard: T&S in labor and assessment for risk of postpartum hemorrhage

               Active Management of 3^rd stage of labor

               Consider prophylactic Tranexamic Acid

               If PPH risk score is 3 prior to induction of labor, transfer care to Anchorage prior to induction. Contact OB unit to help with calculating the score if needed.

HISTORY OF GESTATIONAL HYPERTENSION/PREECLAMPSIA with or without SEVERE FEATURES/ECLAMPSIA

               Aspirin 162mg daily from 12 until delivery.

               Baseline labs: Protein/Creatinine ratio, CBC, CMP.

               Monitor for signs or symptoms of preeclampsia and repeat labs as needed

HISTORY OF SEIZURE DISORDER

               Begin Folic Acid 4mg daily ASAP

               Draw Drug level for current medication

               Consult HROB or OB/GYN for possible medication change

               DAFUS US at 18-22 weeks in Anchorage

               Monitor symptoms and drug levels as needed

               Monitor drug levels Postpartum as physiology changes

               Consider adding vitamin K 10mg daily from 36 weeks to delivery

               Do not give Tdap vaccine.

HISTORY OF SHOULDER DYSTOCIA

               US for growth at 36 weeks.

               Transfer to ANMC at 36 weeks for delivery.

HISTORY OF SKELETAL DYSPLASIA OR DWARFISM

               If this occurs in any pregnancy, refer for genetic counseling.

               If counseling states there is a recurrence risk, refer to ANMC Perinatology at 1^st Prenatal Visit.

               Refer all patients for DAFUS and Perinatology consultation

               Follow plan from ANMC Perinatology note

HISTORY OF SUBSTANCE ABUSE

               Discuss at EVERY visit

               Monitor for signs or symptoms of abuse

               Behavioral Health referral

               If opioid, refer to Suboxone clinician

               Urine drug screening frequently

HISTORY OF STILLBIRTH

               At first prenatal, attempt to locate the post stillbirth workup in the chart and document the results in your note for HROB conference.

               Add Bile Acids and LFT to the 1^st OB visit labs.

               Ultrasound for growth at 24, 28, 32 and 36 weeks.

               Visits every 2 weeks in Bethel after 28 weeks.

               Fetal Kick counts after 28 weeks

               Further planning after HROB meeting based on other diagnoses and risk factors.  See ACOG Practice Bulletin 102 Management of Stillbirth

               BPP weekly after 32 weeks.

               Offer induction at 38 weeks.

HIV disease NEW

               See Guideline

               Contact EIS (907-7292907 or Tiger Text role “ANMC Discharge Scheduler HIV/EIS Clinic”) ASAP for notification and/or medication start

               Get initial HIV labs based on recommendations from EIS

               Follow HIV in pregnancy Guideline

               CD4 count and viral load at 24 and 36 weeks

               Refer to Perinatology

               See guideline for decision of where to deliver

HIV disease previously known

               See Guideline

               Continue HAART

               Contact EIS (907-7292907 or Tiger Text role “ANMC Discharge Scheduler HIV/EIS Clinic”) for notification and/or medication change

               CD4 count and viral load at first prenatal, 24 and 36 weeks

               Refer to Perinatology

               See guideline for decision where to deliver

HYPERTHYROID prior to pregnancy

               Discuss with HROB or OB/GYN at first visit.

               Draw TSH, Free T4 at first visit and at least each Trimester.

               Redraw TSH and Free T4 4-6 weeks after a dosage change.

               Contact Perinatologist to determine need to change Methimazole, change to PTU for first trimester or stop all medications.

               If on PTU, continue at present dose.

               Monitor for signs and symptoms of hyperthyroid disease at every visit.  (goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)

HYPERTHYROID new diagnosis

               Discuss with HROB or OB/GYN at diagnosis or if severe disease suspected.

               Draw TSH, Free T4 at first visit and at least each Trimester.

               Redraw TSH and Free T4 4-6 weeks after a dosage change.

               Observe carefully for signs and symptoms of Thyroid storm. (severe hypertension, goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)

               If tachycardic, start Atenolol 25mg daily

               Begin PTU at 50mg po TID, draw labs weekly until stable.              

               Monitor for signs and symptoms of hyperthyroid disease at every visit. (goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)

HYPOTHYROID prior to pregnancy

               Order TSH, Free T4

               Do not treat subclinical disease

               If previous thyroidectomy or ablation, increase levothyroxine dose by 25% in first trimester and measure TSH and Free T4 every 4-6 weeks until results are stable.

               For all others, measure TSH, Free T4 each trimester.

             

HYPOTHYROID new diagnosis

               Begin levothyroxine ASAP at approximately 100mcg daily

               Check TSH Free T4 monthly until dosage stable

               Check TSH Free T4 every trimester thereafter

               Re-evaluate postpartum

INTRAHEPATIC CHOLESTASIS (IHCP) – Severe itching and abnormal Labs

               Start ursodiol 600 mg BID.  You may increase dose up to 900mg TID for continued severe pruritus.

               Start weekly BPP at 32 weeks

               Redraw Total Bile Acids (TBA) and LFTs weekly after 32 weeks

               May return home with weekly visits

               Consult HROB meeting or obstetrician

               Correct TBA by subtracting the urodeoxycholic acid (ursodiol) from the TBA on the results.

               Severe IHCP if corrected TBA >40, must be induced at 37 weeks in Anchorage.

               If corrected TBA > 100, induce at 35-36 weeks in Anchorage.

               Mild IHCP, TBA < 40, induce at 38 weeks.

IUGR see Fetal Growth Restriction

LTBI

               If prior tuberculosis diagnosis with completed treatment, diagnosis of LTBI.

No PPD or Quantiferon

               Ask about symptoms: hemoptysis, fever, night sweats, weight loss, or cough.

               If all symptoms are negative, no reactivation of TB and no treatment or diagnostic testing needed.

MIGRAINE HEADACHES

               Discontinue triptan medication

               Low dose tricyclics OK after 1^st trimester

               Tylenol.

               If above fails, refer to Neurology.

               Avoid opiates.

OBESITY

               If BMI >40, refer to HROB meeting for consultation.

               If BMI >40 and patient 36 weeks gestation or later, Consult HROB on call and on call CRNA on call for consultation regarding suitability for delivery in Bethel.

               For all women with BMI> 35, obtain US for growth at 28, 32 and 36 weeks and start BPP weekly at 32 weeks.

POSITIVE ANTIBODY SCREEN

               Confirm antibody identification.

               If antibody is Kell, Duffy (Fy), c, C, D, e or E, contact OB/GYN or discuss at HROB ASAP

               Any other antibody, contact OB/GYN for plan of management.

               Obtain Unity cell free DNA screening for T21, T18, T13, sex chromosomes and the antigen identified above.  The testing kits are available at the Team Room C nursing station.

               If fetal antigen testing is negative, no further testing is needed.

               If fetal antigen testing is positive, refer to MFM for plan of care to monitor for isoimmunization.

POSITIVE HIV SCREEN

               Confirm HIV status with reflex testing.

               Once HIV disease confirmed, see HIV Disease, New

PLACENTAL ABNORMALITIES

LOW LYING: <2.5cm from internal os of the cervix

               Repeat transvaginal ultrasound monthly until resolved.

               If not resolved by 32 weeks, consult Perinatologist for further plan of management

CIRCUMVALLATE

               At risk for growth restriction.  Growth US at 32 weeks to assess for growth restriction.

SUCCENTURATE LOBE

               Make sure ultrasound has screened for vasa previa

               At delivery, ensure entire placenta is removed during 3^rd stage.

VELAMENTOUS CORD INSERTION

               At risk for growth restriction.  Growth US at 32 weeks to assess for growth restriction.

PLACENTA PREVIA

               Placenta previa diagnosed at second trimester ultrasound

                               Repeat ultrasound at 24 weeks.

                               If still a previa,

                                               Pelvic rest: no sex, no exams

                                               Transfer to Anchorage until previa resolves.

               Before 24 weeks, no need to change activity unless actively bleeding

PREDIABETES

               Refer patient to Diabetes and prescribe supplies for finger stick testing

               Review testing results weekly at HROB rounds with diabetes team

               Screen for GDM as per routine care

PREVIOUS CESAREAN

               If considering repeat cesarean in Bethel, appointment with OB/GYN ASAP

               Refer to HROB meeting for discussion

               Repeat Cesareans done in Bethel unless there is a medical reason for the transfer.

               Document patient’s choice of location and route of delivery, in note and as comment in diagnosis.

               Provide trial of labor after cesarean (TOLAC) education and first prenatal visit.

               Complete TOLAC consent ASAP

Rh negative

               See Guideline.

               Repeat Type and Screen with Rhogam work up at 28 weeks.

               If RH negative, Give Rhogam at 28 weeks.

               At delivery, follow OB guideline for Rh negative patients.

RUBELLA NON-IMMUNE

               Repeat MMR vaccine postpartum if the patient has fewer than 3 lifetime MMR vaccines

SHORT CERVIX ON SCREENING

               History of Preterm Birth

                              Cervical length less than 25mm

                                               Consult with MFM provider to discuss cerclage

                               Cervical length 26 to 29mm

                                               Weekly cervical length ultrasound

                               Cervical length 30mm, continue every other week cervical length measurements until 24 weeks.

               No History of Preterm Birth

                               Cervical length 20mm or less

                                               Vaginal progesterone 200mg qhs

                                               Repeat cervical length in 1-2 weeks

                               Cervical length 10mm or less

                                               Consult MFM or OBGYN for possible cerclage

SUBOXONE TREATMENT

               Make appointments with Dr Compton or another MAT/Women’s Health (WH) provider

               UDS as needed (does not need to be every week), Tramadol and/or gabapentin levels depending on patient’s drug use history

               Transfer to Anchorage at 36 weeks or sooner for delivery

TWIN GESTATION (Diamniotic-Dichorionic)

               Add Folic Acid 1mg daily

               Aspirin 162mg daily from 12 weeks until delivery

               18 Weeks ANMC

                               TV ultrasound for cervical length

                               Early DAFUS,

                               Counseling

               22 Weeks ANMC

                              Full DAFUS

               24 Weeks YKHC

                               Prenatal visit

                               1 hr. GST, CBC

               26 Weeks YKHC

                               Prenatal visit

                               Ultrasound for fetal growth and TV ultrasound for cervical length

               28 Weeks YKHC

                               Prenatal visit

               30 Weeks YKHC

                               Prenatal visit

                              Ultrasound for fetal growth and TV ultrasound for cervical length

                              ** BE IN BETHEL due to high risk pregnancy **

               31 Weeks YKHC

                               Prenatal visit

               32 Weeks YKHC

                               ** Transfer to ANMC until delivery**

TWIN GESTATION MONOAMNIOTIC-DICHORIONIC OR MONOAMNIOTIC-MONOCHORIONIC

               Add Folic Acid 1mg daily

               Aspirin 162mg daily from 12 weeks until delivery

               16 weeks – Appointment in Anchorage to evaluate for twin-twin transfusion syndrome

                              All future appointments in Anchorage

UTERINE SHELF

               Repeat ultrasound in 4 weeks.

               These rarely are a problem

UTI IN PREGNANCY

               Urine Culture every visit

               Prophylaxis after 2^nd UTI or 1st pyelonephritis: recommend Nitrofurantoin 100mg po qhs.

TOLAC in Bethel, Planned

               Discuss Case at HROB meeting

               At BIB, provider will contact the HROB on call, blood bank lead, OB charge nurse.

               On admission in labor: Admitting physician will notify CRNA on call, HROB on call.

               Complete TOLAC Consent at earliest prenatal visit possible          

VITAMIN D DEFICIENCY

               SELECT ONLY ONE SENTENCE FOR NOTE

               25-OH Vitamin D > 20ng/ml Continue cholecalciferol 1000 IU daily (standard for all patients)

               25-OH Vitamin D > 12ng/ml and <20ng/ml increase cholecalciferol to 3000 IU daily

               25-OH Vitamin D < 12ng/ml

               If < 32 weeks, increase cholecalciferol to 3000 IU daily

               If > 32 weeks give ergocalciferol 50,000 IU weekly for 12 weeks.

category:Women's Health